ProQOL and Penn Inventory Scores
Burnout subscale scores ranged from 2 to 38, with a mean score of 20.56 (±6.34). In this sample, 35.9% (n = 48) of nurses had BO scores of greater than 22, suggestive of BO or a higher risk of BO. Compassion fatigue subscale scores ranged from 1 to 39, with a mean score of 13.94 (±7.19). Compassion fatigue, as indicated by subscale scores of greater than 17, was reported by 27.3% (n = 35) of trauma nurses. Compassion satisfaction subscale scores ranged from 9 to 50 (mean = 37.96 ± 7.62). The majority of the sample, 78.9% (n = 101), demonstrated above average CS, whereas 21.1% (n = 27) of nurses had scores less than 32, which indicated low CS. Scores on the Penn Inventory ranged from 1 to 54, with a mean of 18.5 (±10.24). Nine nurses (7%) had Penn scores greater than 35, consistent with STS.
Relationship of Burnout, Compassion Fatigue, and Compassion Satisfaction With Secondary Traumatic Stress
Pearson correlations were used to examine the interrelationships of the 3 components of the ProQOL scale (BO, CF, and CS). Burnout and CF both correlated negatively with CS (p ≤ .000). Thus, higher BO and CF scores were associated with lower CS scores. Burnout and CF correlated positively (p ≤ .000). Trauma nurses with higher BO scores tended to have higher CF scores.
Pearson correlations were conducted to evaluate the relationship of the components of the ProQOL scale (BO, CF, and CS) to the Penn Score (STS) (Table 2). Both BO and CF correlated to STS (p ≤ .000). Higher CS was associated with lower STS (p ≤ .000).
Burnout, Compassion Fatigue, and Compassion Satisfaction as Predictors of Secondary Traumatic Stress
Linear regression analyses were performed to examine whether BO, CF, and CS, as assessed with scores on the ProQOL, predicted STS as measured by Penn Scores (Table 3). The model was significant—F (122,3) = 22.202; p ≤ .000—and predicted 35.9% of the variability in STS. Within the model, BO and CS were significant predictors of STS. Trauma nurses with higher levels of BO had higher STS (p = .001). Conversely, those nurses with higher CS had lower STS (p = .006).
Relationship of Burnout and Personal/Environmental Characteristics, Coping Strategies, and Exposure to Traumatic Events
Pearson correlations were used to examine the relationship of BO to personal/environmental characteristics, coping strategies, and exposure to traumatic events (Table 4). No significant correlations existed among BO and personal/environmental characteristics.
The variable “supports” represented weighted support, the number of support systems combined with the reported strength of support. Within coping strategies, BO was negatively correlated with supports (p < .0002), exercise (p ≤ .000), and meditation (p ≤ .000). Burnout positively related to the coping strategies of seeking professional counseling (p = .022) and use of medicinals (p = .001). Burnout correlated with coworker relationships (p ≤ .000). Nurses with greater BO reported poorer coworker relationships. Within exposure to trauma category, BO related to years in current position (p = .037), hours per shift (p = .005), and percentage of time in direct patient care (p = .006). A higher percentage of time in direct patient care, more years in current position, and more hours per shift (12 hours vs 8 hours) were associated with greater BO.
In summary, trauma nurses with greater BO sought professional counseling, reported using medicinals, had more years in their current position, more time in direct patient care, and worked more hours per shift. These nurses also reported that they had fewer supports, got less exercise, had poorer coworker relationships, and used less meditation.
Relationship of Compassion Fatigue and Personal/Environmental Characteristics, Coping Strategies, and Exposure to Traumatic Events
Pearson correlations were used to examine the relationship of CF to personal/environmental characteristics, coping strategies, and exposure to traumatic events (Table 4). Compassion fatigue did not correlate significantly with personal/environmental characteristics.
Within the coping strategy category, CF correlated negatively with hobbies (p = .022) and coworker relationships (p = .001). Thus, trauma nurses with higher CF had fewer hobbies and reported weaker coworker relationships. Trauma nurses with greater CF used more medicinals (p = .006). Within the exposure to the traumatic event category, CF correlated with working more hours per shift (p = .006).
In summary, trauma nurses with greater CF reported higher use of medicinals and worked more hours per shift (12 hours vs 8 hours). Nurses with lower CF used hobbies as a coping strategy and reported positive coworker relationships.
Relationship of Compassion Satisfaction and Personal/Environmental Characteristics, Coping Strategies, and Exposure to Traumatic Events
Pearson correlations were used to examine the relationship of CS to personal/environmental characteristics, coping strategies, and exposure to traumatic events (Table 4). Within personal/environmental characteristics, greater age (p = .039) and lower education levels (p ≤ .000) correlated with CS. Within the coping category, CS correlated with number and strength of supports (p ≤ .000). Higher reported strength and numbers of supports were positively related to higher CS and fewer supports related to lower CS. Nurses who used more exercise as a coping strategy had higher CS (p = .042). Use of meditation as a coping strategy was associated with higher CS (p ≤ .000). Use of medicinals as a coping strategy associated with lower CS (p = .024). Finally, trauma nurses reporting weaker coworker relationships had lower CS (p ≤ .000). There were no significant correlations between CS and the exposure to traumatic events variables.
In summary, within this sample of trauma nurses, greater CS related to older age, greater strength and numbers of supports, use of exercise and meditation, and more positive coworker relationships. Lower CS related to higher levels of education and use of medicinals.
Our study findings of trauma nurses from a large, urban, academic medical center supported our theoretical model; we found relationships among BO, CF, CS, and STS in trauma nurses. A large percentage of nurses in this study, 35.9%, had ProQOL scores consistent with BO or high risk of BO, whereas 27.3% reported CF, and 9% had scores consistent with STS. More than 75% of trauma nurses in this study experienced CS related to caring for traumatically injured patients. These results are comparable to those of a study of nurses from ED, critical care (ICU), oncology, and nephrology units that also used the ProQOL survey. Compared with the current investigation, this smaller study reported slightly lower percentages of ED and ICU nurses with BO (22% and 34%) and similar percentages of nurses with CF (ED 29%, ICU 28%).11 Unlike the current study, previous research found higher levels of CF than BO.6,11
Of the relationships between BO, CF, and STS in this sample of trauma nurses, BO and CF had the strongest correlation. This in part may be the result of the strain and fast pace related to solely caring for trauma patients on a daily basis. However, CS was high in the majority of respondents, suggesting that nurses in this sample derived significant professional satisfaction from their work in a trauma center. High CS was also negatively related to BO, CF, and STS. As in our study, Yoder6 reported that nurses with higher CS scores had lower BO and CF scores of the ProQOL. Similarly, intensivists that reported lower levels of personal accomplishment in their work had higher levels of BO.28 As indicated in our theoretical model, BO and CS were predictive of STS. Higher BO scores predicted higher STS in our sample. Conversely, a high CS score was the strongest predictor of STS. Nurses with higher CS scores were less likely to develop STS. This may be indicative of the nature of nurses who choose to work exclusively with trauma patients; however, studies are needed that compare trauma nurses with those working in other specialty areas.
Burnout in trauma nurses, although unrelated to any personal/environmental characteristics, was related to certain types of coping strategies such as use of medicinals and seeking counseling. It also related to greater exposure to trauma patients, for example, from working more hours per shift. This same finding was reported in ED and ICU nurses.11
Coworker relationships seem to have a significant influence on BO. ED nurses reported the use of colleague support and supportive social networks to prevent BO.18 The association of BO with less support from coworkers and negative relationships with coworkers is a consistent finding among ED and critical care practitioners28–31 A large study of 95 499 nurses supported these findings: nurses with poor work environments and more time in direct patient care had higher levels of BO.7 Studies of intensivists, critical care nurses, and new graduate nurses with fewer years of experience had higher levels of BO.10,28,30,31 Our sample was unique in that nurses with more years in their current position had higher BO scores. The uniqueness of the trauma work environment and years in nursing in this sample may have influenced BO.
Compassion fatigue was less prevalent than BO in this study and was related to hours per shift, work relationships, and coping mechanisms. Similar to the factors influencing BO, CF occurred in those trauma nurses who reported fewer hobbies, weaker coworker relationships, working 12 rather than 8-hour shifts, and using medicinals. In a mixed method study of clinicians working with trauma survivors, having lower emotional self-awareness predicted higher CF.32 Nurses reported that caring for challenging patients, futile care, work environment stressors, and personal experience triggered CF.6 Health care providers working with trauma survivors identified “work drain” as predictive of CF, whereas self-care strategies, such as addressing personal needs, helped them to avoid CF.32 The stress of working in an environment that entirely serves trauma victims combined with more work hours of exposure to trauma patients may, in part, explain why trauma nurses in this study had more CF with increased hours per shift.
An important finding of our study was the high prevalence of CS in this sample of trauma nurses. Personal/environmental characteristics of greater age and lower education correlated with CS. In mental health professionals, increased age predicted CS25,33 and those with trauma training had higher CS scores on the ProQOL.25 In our sample, those with higher levels of education had less CS, which may have been a reflection of a limited professional advancement model that was in place at our institution at the time of data collection. Nurses with higher levels of education had limited opportunities for professional advancement, and this may have contributed to decreased satisfaction. Interestingly, others have reported that ICU nurses with higher levels of education (bachelor's and above) suffered more moral distress or higher levels of BO than those with associate degrees.34
Not surprisingly, trauma nurses in this study who reported stronger support systems, use of exercise and meditation, and positive coworker relationships had higher CS. Similarly, a study of clinicians working with trauma survivors noted that increased social support, fewer hours per week, and an internal sense of control over work environment were associated with CS.32 Stronger coworker relationships may create a more positive work milieu that impacts the reported satisfaction from caring for trauma victims in a high-stress environment.
The current study had several limitations that must be acknowledged. Although we had nearly a 50% response rate, the sample of nurses (n = 128) from a single trauma center was relatively small and homogeneous. Limitations in self-report data such as social desirability cannot be overlooked. There may be differences among those nurses who responded to the survey and those who did not. Findings in relationship to STS must be interpreted with caution as the actual number of nurses within our sample that exhibited scores consistent with STS was relatively low. The tool used to assess STS in nurses, the Penn Inventory, although recommended as an instrument to assess stress in working with the traumatized,9 has not been widely validated in nursing populations.35,36 There are limited instruments that are specific to nursing that assess STS, and none of these instruments are specific to the trauma nursing population.9 The reliability on the ProQOL BO, CF, and CS subscales was slightly higher than previously reported.23 The Penn Inventory and the ProQOL require further investigation and validation in the trauma nurse population. Despite these limitations, this study represents an important preliminary step in identifying factors related to BO, CF, CS, and STS in trauma nurses and highlights the need for more research in this area.
Additional research may elucidate why some trauma nurses develop BO, CF, and STS, whereas others report high levels of CS. Exploration of coping strategies and interventions to reduce BO, CF, and STS and to maximize CS is necessary. Longitudinal studies, including nurses from multiple trauma centers, may better define the effects of caring for trauma patients over years of nursing practice. Studies are needed that compare trauma nurses with nontrauma nurses to explore whether these findings are unique to the trauma nursing population. Motivation for working in trauma nursing also needs to be explored. In our sample, BO and CF were not related to personal/environmental characteristics but were related to coping and exposure to trauma—two areas in which interventions could be developed to potentially mitigate BO, CF, and STS in trauma nurses. Hospitals serving large trauma populations may benefit from examining strategies that increase CS in nurses while decreasing the negative effects of caring for trauma patients such as BO, CF, and STS. Future research could also explore whether there is a link between BO, CF, STS, CS and patient satisfaction scores. Staff support programs, such as access to resources and education, may help nurses experiencing the effects of caring for patients with traumatic injuries.37 One of the most consistently reported characteristics that reduces BO, CF, and STS, and is positively associated with CS, is the strength of relationships with coworkers. Strategies that enhance a healthy work environment merit deliberate attention and further exploration.
Caring for trauma patients on a daily basis can be rewarding and is associated with a high degree of CS. Conversely, trauma nurses may experience BO, CF, and STS. Although the relationships of BO, CF, and STS to each other were supported by our study, further investigation is needed to explore why these develop in some nurses and not in others. A better understanding of the causes of BO, CF, and STS may enable nurses to take necessary steps for prevention and recognition of impending development of BO, CF, and STS. The concept of CS also requires more consideration in both trauma nurses and the general nursing population. This study highlights a need for additional research in nurses caring for trauma patients and development of interventions, institutional policies, and support programs related to BO, CF, CS, and STS.
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Keywords:Copyright © 2014 by the Society of Trauma Nurses.
Burnout; Compassion fatigue; Compassion satisfaction; Secondary traumatic stress; Trauma nursing